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1/13/09
Diff Dx (midterm material)
LBP, Is it pathomechanical, pathological, mixed, or psychosocial?
-pathomechanical (97-98% of patients) aberrant joint function
-pathological (1-2%) infection, neoplasm, vascular, etc
-threatening/lethal
-nature does not support an immune system that is in isolation socially
Etiological components of LBP
-anatomic
-physiologic
-psychosocial
-doctor should encourage an exchange in knowledge, rather than feel threatened when patient asks questions
-abrupt, dismissive behaviors are common amongst clinicians and are a violation of the psychosocial model
-pain perception only occurs above the thalamus
-below the thalamus, these signals are called nociceptors
1/22/09
-difference b/n primary, secondary, and tertiary care
-specialists are secondary & tertiary care
-tertiary care occurs at the hospital
-prevention is all about risk-factor identification
-primary prevention: apply care which does not allow a risk factor to be established
-secondary prevention: patient has risk factor, and thus works to reduce the risk factor
-tertiary prevention (aka rehabilitation): reducing the risk factor after the disease is already contracted
-hippocampus is the most sensitive area of the brain to hypoxia
-there is no linear relationship between tissue damage and pain (due to processing)
-the descending pathway could either inhibit or facilitate nociceptive signals
Dimensions of Pain
-sensory: discrimination
-primary and secondary sensory cortex
-“where and how much do you hurt?”
-affective: emotional
-anterior cingulate, insula
-cognitive: attentional
-prefrontal
-a lot of activity in the medial prefrontal cortex in patients with chronic pain
-post parietal
-emotion and attention can fuel (by themselves) the perception and consciousness of pain
-religious experiences can also provide profound states of anesthesia
-when people are attentive to their pain all day long, then they are locking in those neurological pathways
1/29/09
Evaluation of the patient encompasses: anatomic, physiologic, and psychosocial factors
Psychosocial factors
-motivation
-perception/cognitive function
-affective behavior
-social behavior
-work/family dynamics
-job satisfaction
-coping strategies (diet, meditation, hiking, etc)
Psychosocial Dysfunction in LBP
-acute phase associated with fear/worry/anxiety
-fear: means an immediate threat is responded to (the truth of the circumstance doesn’t matter)
-you can usually block fear with knowledge
-anxiety: the expectation of a threat over a period of time
-a state of devastation that results in the continuous expectation of something bad
-fear is “right now”, but anxiety is over a “future period”
-catastrophization: the only thing that can happen is something bad
-this activates the HPA axis (stress)
-stress, anger, somatization
-hypothalamic-pituitary-adrenal (HPA) axis = stress responder
-somatization: can project dysfunction into a system (ie an organ, muscle, or joint)
-ie fear/anxiety can be deposited in a system
-learned helplessness, learned sick roles
-motor output dysfunction
-learned sick roles: could walk with a disturbed gait even though physical exam is normal
-physical deconditioning
-depression
-typically comes from long-term anxiety
Diagnostic Approaches to LBP
-red flag
-pattern recognition
-algorithm
2/3/09
Reg Flags of LBP (2% of patient population)
-history
-malignancy
-m/c malignancy: skin (basal and squamous cell carcinomas)
-color change
-bleeding
-growing
-melanoma is responsible for 70% of all skin cancer deaths
-bone-seeking tumor (BLT Pickles Ketchup and Hot Sauce)
-spinal manipulation can block cancer pain for a day or two, but it always returns shortly
-immunocompromise
-diabetic (glucose bothers 3 systems: vascular, neuro, immune)
-lipids (low-fat diets lower the risk of malignancy)
-decrease antibodies with age, and increase auto-antibodies
-coagulopathy
-new onset over 50yo
-most patients with degenerative musculoskeletal complaints occur before 50yo
-presenting complaint
-traumatic onset
-nocturnal pain (patient awakened by pain)
-m/c cause of nocturnal awakening is large joint OA
-malignancy can also awaken the patient
-absent postural provocation
-bilateral radiculopathy
-indicator for MRI (don’t even do trial of care on this patient)
-buttock or perianal numbness
-changes in bowel/bladder habits
-*caudae equina syndrome (know symptoms): neurosurgical emergency
-painless lower limb weakness
Red Flags of LBP cont…
-exam findings and lab tests
-pulsatile abdominal mass (AAA)
-AAA risk factors: male, long-standing hypertensive, and smoking history
-bilateral neuro deficits
-increasing neuro levels
-progressive neuro deficits
-fever
-incr ESR, decr WBC, decr Hg points toward systemic disorder
-normal sed rate: 15mm/hour
-if fractionated proteins (broken cells from a pathological process) then elevated sed rate
-if elevated sed rate along with chronic unresponsive pain, then need bone scan
-failed conservative trial
-suspicion of referred pain (ie pain associated with eating, menses, flank, writhing)
-pain distant from the origin of the pain generator distracts from the underlying accuracy
SystemsVICTANEDDXTesting Strategy (imaging, lab, physiological tests, trial of care)
-diagnosis (in ambulatory care) does not require the certainty that it would for surgical care
2/12/09
-58yo female with LBP & left leg pain after moving couch
-pain to toes
-coughing/sneezing did not increase it
-left antalgia & severe paravertebral muscle spasm
-moderately obese
-Minors sign positive on left (push off yourself to climb up)
-Bechterrew’s negative
-tenderness over L4 SP with percussion
-SLR positive on left
-hypesthesia of left L5/S1 dermatomes
-myotomes: 2/5 for L4/L5/S1
L4/5 sequestered disc
-m/c cause of epidural mass is a sequestered disc
2/17/09
Disc herniations (classified should not affect tx)
Protrusion – base is wider than the part that extends into the canal
Extrusion – base is longer than it is wide
Sequestration – a fragment has separated off from the NP
-bulge is only significant if it accompanied by a stenotic canal
-bulges are not known to progress to herniations and should not be a significant finding
-what category should herniations be placed in? arthritide (not trauma)
-if myelopathy (cord signs; UMNL), then HVLA should be avoided
-herniations increase as a function of age until the age of 50
-after 50, then stenosis starts occurring
Stenosis locations
1)central canal stenosis
2)lateral recess stenosis
3)neuro foramen stenosis
Stenosis causes (classifications)
-degenerative
-post operative
-post trauma
-congenital
2/19/09
-Preferential treatment for spinal stenosis: L/S flexion
-desire to see centralization of pain
-if patient doesn’t centralize, then the odds are that they won’t do well under a trial of care
-might need epidural block, or surgery
-stenosis in C/S, risk is: root compression and/or cord compression
-spondylotic myelopathy = stenosis in C/S causing cord compression
-radiculomyelopathy = root AND cord compression
2/24/09
Primary headaches (idiopathic) (most headaches)
-Tension, vascular, mixed
Secondary headache (pathological)
-infection, tumor, etc
-if inside the skull, then vascular, or neoplasm
-vascular space occupying lesion: neoplasm, aneurysm
-what neoplasm is most common in the brain: meningioma(benign)
-most common malignant neoplasm in brain: glioma
-headache with neuro deficits = pathological (secondary) headache aneurysm or neoplasm
-traction headaches
-pushing/pulling of tissues
-vascular headache is reserved for migraine and cluster
-there is an area of brain ischemia associated with migraine HA
-mesencephalon (red nucleus and substantia nigra, in particular) seems to be the central trigger for migraines
-migraines appear to be a CAN disorder
-masses originating in the brainstem lead to multiple CN deficits (not just one cranial nerve)
-how common is an aneurysm? 5-7% (same prevalence as spondylolisthesis)
-large aneurysm = 25mm (ischemic changes, such as memory fading)
-coughing: intra-abdominal pressure increases causes the aneurysm to swell
-physical activity generating a headache = “cough headache”
2/26/09
-there is no evidence that people who take high doses of calcium get urinary stones
-rather there is some evidence that you have some protection from stones with high calcium intake
-enlargement of bone in the 50+yo age group would be consistent with Paget’s disease
-Paget’s moves through bone
-it is notorious in people over 60yo (1/10 after 60 has Paget’s, but usually they are asymptomatic)
-Paget’s = osteitis deformans (a bone infection)
-soft, cheap bone that then deforms
-spinal stenosis is seen in Paget’s patients
-elevated serum alkaline phosphatase
-hyperparathyroidism
-all osteoporotic patients have elevated parathyroid levels
-“blade of grass deformity”
-polyostotic
-soft bone of skull, leads to entire skull traveling down and c/s invades the brainstem
-basilar invagination
“chamberlain’s line” odontoid process moves above the foramen magnum, and into the brain
-allopathic tx: craniectomy (removal of the base of the skull)
4 phases of Paget’s:
-lytic
-mixed
-blastic
-malignant degeneration
-pharmacologic tx stops osteoclastic activity, and stimulates osteoblastic activity
3/3/09
CASE:
-20yo squatting 325lbs, sudden left-sided paresthesias and weaknesses (both LE and UE)
-mild tenderness over C7 and T1, 4+ strength in L biceps, wrist extensors, triceps, quad, hamstrings, and ankle dorsiflex
-hyperrreflexia throughout left UE and LE, babinski negative
-burning dysesthesias radiating into hand and foot
-c/s radiograph negative (no fractures, no instability, no soft tissue swelling)
-MRI: intramedullary cord lesion from C3/4 to C6/7
-cerebellar tonsils extended 8mm below foramen magnum (Arnold Chiari)
-congenital syrinx that became symptomatic with weight lifting (syringohydromyelia)
A few notes from the Family Medicine text
-spinal manipulation has been shown to speed recovery within first month of LBP symptoms (p277)
-LBP patients should be encouraged to begin low-impact aerobic exercise (walking, swimming, cycling) as soon as
possible; more rigorous exercises to improve abdominal and paraspinal mm tone should be delayed for at least 2
weeks following the onset of symptoms (p277)
-for OA, capsaicin cream is effective for pain relief (esp in OA of knee or hand); requires 4x/day application (p537)
-for OA, glucosamine (1500mg/day in 3 divided doses) and chondroitin (800-1200 mg/day in 3 doses) appear to provide
some pain relief; other herbal agents that may have some benefit include:
- S-adenosylmethionine (SAMe), 400-1200 mg/day
- topical dimethyl sulfoxide 25% gel (DMSO)
- avocado/soybean unsaponifiables, 300 mg/day (p 537)
-specificity = true negatives
-sensitivity = true positives
********************** End midterm material **************************
3/10/09
DDX chest pain
-defn: chest pain is the sensory response to noxious stimuli caused by trauma or dysfunction of the chest wall, thoracic organs, and contiguous structures. Psychological disorders can cause chest pain where no organic disease exists and can precipitate and exacerbate organic causes of chest pain
Common diagnoses
-cardiac chest pain
-including myocardial ischemia, infarction, and pericarditis
-viral infection is m/c cause of pericarditis
-aortic chest pain
-caused by acute aortic aneurysmal distention and aortic dissection
-hypertension is most significant risk factor (smoker, hypertensive, and over 60)
-tracheal and pleural chest pain
-from tracheitis, pulmonary embolus or infarction, pneumonia, or pneumothorax
-diaphragmatic chest pain
-from adjacent pericarditis, pneumonia, acute pancreatitis, subdiaphragmatic abscess, and penetrating and perforated
peptic ulcers
-gastrointestinal chest pain
-caused by esophagitis, esophageal spasm, esophageal obstruction, or esophageal rupture; peptic ulcer disease;
pancreatitis; biliary tract disease; or acute liver distention
-integumental, skeletal, and muscular chest pain
-from herpes zoster, chest wall trauma, costochondritis (Tietze’s), or rib, cervical, and upper thoracic spine disease
-breast-related chest pain
-from fibrocystic breast disease, mastitis, trauma, cellulitis, herpes zoster, or other dermatoses
-vascular chest pain = cardiac, aortic, and pulmonary embolus
-atherosclerosis:
-combination of: lipids, stress hormones, and inflammation
-stress hormones in a lipid environment
-if patient gets a warning (heavy pressure on chest): angina
-Goldman’s sign: take fist and drop it over sternum (classic sign for cardiac ischemia)
-if sharp pain in chest, then it is inconsistent with ischemic disease
-walking through the pain (of claudication) will trigger angiogenesis
-Big 3 rule out: infarction, dissection, pulmonary embolus
-post-op patients are the most common to experience pulmonary embolism
-outside of the hospital the biggest risk factor for pulmonary embolism is: immobilization
-other risk factors for pulmonary embolism:
-smoking, corticosteroids, deep vein thrombosis
-pulmonary embolism with infarction is the most threatening scenario
-15% of pulmonary emboli result in infarction
-pleural inflammation (or pleuritic chest pain): pain with inspiration
-pain with inspiration is also a sign of rib instability
-esophagitis is typically due to eating a large meal and then lying recumbent (more likely to reflux)
-nocturnal sources of chest pain: pancreatitis, biliary tract disease; acute liver distention
-“presby” = age-related abnormality
-presbyesophagus: entire esophagus contracts at once esophageal spasm (can cause acute chest pain)
-eating fast (and while stressed) could cause an esophageal spasm at any age
-sometimes a little sip of water might help stop the spasm
-under 30yo, costochondritis (Tietze’s) is m/c cause of chest pain
3/17/09
-if pain in a diabetic, first think: vascular
Tietze’s (common cause of chest pain)
-small parasternal nodule (in the costochondral cartilage)
Normochromic normocytic anemia
-chronic renal disease
-crowding of marrow myelophthisic anemia (no room to produce RBC’s)
-alk phos increases when there is bone turnover (bone repair or bone damage)
-increased sed rate:
-connective tissue disease (polymyalgia rheumatica, SLE, etc)
-malignancy (however ESR is not always elevated with malignancy)
-high sensitivity C-reactive protein (HS-CRP) is a good prediction for vascular disease
-non-Hodgkin’s is about 20x as common as Hodgkin’s lymphoma
-frequently there are no nodes associated with non-Hodgkin’s
-malignant disease of bone can grow everywhere there is hematopoietic tissue
3/19/09
-iron deficiency anemia (& fatigue) in an adult: bleeding in GI or GU
-hopefully it is just an ulcer, but it could be colon carcinoma
-most colon polyps grow because of constipation
-metabolite in bile is carcinogenic
-colon carcinoma is almost non-existent in vegetarians (because of the high-fiber load)
-every time a culture shifts from vegetable-protein sources to meat-protein sources, there is an increase in colon carcinoma
-if Respiratory Rate over 20 = Pulmonary Embolism until proven otherwise
-V/Q mismatch: normal ventilation, but perfusion is abnormal
-can breathe okay, but no blood going to the lungs
3/24/09
Risk factors for vascular system:
-Male, Stress, smoker, xanthelasma, family history positive
-people die from an MI about every 20 seconds in the USA
-myocardial ischemic referred pain:
-tightness across the chest, pressure buildup with activity, ache in left arm, strange feeling in throat
-left arm, cervical spine, left mandible (about 10% to the right arm)
-if occlusive disease, then pain with use of the related body parts fed by those vessels
-with many patients, the first sign of coronary artery disease is death
-shortness of breath = reduced cardiac output
-anemia and hyperthyroid could also cause shortness of breath
-single vessel heart attacks: left anterior descending artery (LAD)
-exercise stress test:if ST depression indicates ischemia
-most heart attacks incur in the normal lipid range (200-250)
-stable angina: discomfort subsides with rest
-unstable angina: no pain reduction with rest
-on the brink of moving into the infarction stage
-behavior medication: requires understanding
-stress out of control (anxiety) is just as much a source of vascular injury as diet (eating at McDonald’s)
3/26/09
-the quicker an event occurs, the more likely it is vascular in nature
-incontinence is typically in diabetic patient and it occurs over a period of time
-if in female, then typically stress incontinence and multiparous
-lesions at conus medullaris (L1/2) could have upper or lower motor neuron presentation (cauda equina syndrome)
-aortic dissection ultrasound and confirmed with CT
-70% of patients with dissection have hypertension
-aortic dilation and wall thinning
-congenital aortic valve anomalies
-Marfan’s
-pregnancy
-Ehlers-Danlos
-syphilitic aortitis
-deceleration injury with related chest trauma
-aortic arch hypoplasia
-cocaine use (can have vascular complications with first cocaine use, causing a stroke)
-aortic dissection can result in ischemia of the blood supply to the cord
DDX of nontraumatic lumbar paraplegia:
-HNP, Guillain-Barre, Tumor, epidural or intradural hematoma, epidural abscess, transverse myelitis, cord ischemia
3/31/09
Syncope
A) neurally mediated (is most common cause)
1) vasovagal
-young women, exposure to stress, pain, enclosed space
-unpleasant stimulus, prodrome
2) situational
-elderly, autonomic dysfunction, dehydration, prolonged recumbency, meds
3) carotid sinus
-elderly, atherosclerotic disease.
B) Cardiac
1) arrhythmia
-sick sinus, AV block, meds, pacemaker malfunction, recent MI, tachycardia
2) structural
-VHD, FHx sudden unexplained cardiac death
C) Cerebrovascular
-HTN, dyslipidemia, DM, old age, cigarettes
D) Miscellaneous
-alcohol abuse
-passing out, and falling to the knees, could bilaterally stretch the gastroc and cause calf strain
-if high blood pressure and then faint, then can’t assume neural-mediated event, but rather cardiac event
-plaque that ruptures leads to an ulcer which can cause a thrombus
-asymptomatic heart attack
-most subtle presentation: patient says, “I feel a little blue today.”
4/2/09
-if acute dyspnea (ie 3 days), then respiratory system
-if chronic dyspnea, then likely COPD (or cardiovascular)
-edema: meds, renal disease, or vascular system failure
-if heart can’t pump blood forward, then leads to fluid in base of lungs (rales)
-elevated pressure in venous system (pulmonary venous hypertension)
-3rd and 4th heart sounds are signs of turbulence and hemodynamic strain
-cor pulmonale: chronic lung disease produces heart disease
-normal ejection fraction: 50-60% (amount of blood that ejected out of the left ventricle)
-most heart failure is idiopathic
-usually a heart muscle disorder (confirm with myocardial biopsy)
-pharm tx of heart failure: nitrates
4/7/09
ABDOMINAL PAIN DDX
-defn: subjective discomfort in abdomen